JP2023524789A - Pharmaceutical combination comprising TNO155 and nazartinib - Google Patents

Abstract

The present invention relates to pharmaceutical combinations comprising TNO155 and nazartinib; pharmaceutical compositions comprising the same; and methods of using such combinations and compositions for the treatment or prevention of conditions, wherein SHP2 inhibitors in combination with EGFR inhibition are e.g. , is beneficial in the treatment of cancer.

Description

Pharmaceutical combinations comprising TNO155 and nazartinib; Beneficial in the treatment of cancer. The present invention also relates to TNO155, or a pharmaceutically acceptable salt thereof, for use in treating cancer, wherein TNO155. or a pharmaceutically acceptable salt thereof is co-administered with nazartinib, or a pharmaceutically acceptable salt thereof. The present invention also relates to nazartinib, or a pharmaceutically acceptable salt thereof, for use in treating cancer, wherein nazartinib, or a pharmaceutically acceptable salt thereof, is TNO155, or a pharmaceutically Co-administered with an acceptable salt.

Aberrant receptor tyrosine kinase (RTK) signaling is a common feature of many human cancers and often causes susceptibility to therapies that target these kinases. Examples of such cancers include EGFR-mutant lung cancer, KIT-mutant gastrointestinal stromal tumor (GIST), and HER2-positive breast cancer, as well as head and neck squamous cell carcinoma (HNSCC) and RAS/BRAF-WT colon cancer (CRC). , both of which often overexpress EGFR. SHP2 is a phosphatase that binds activated RTKs and transmits their signaling downstream to the Ras/MAPK and PI3K/Akt pathways. Inhibition of SHP2 therefore inhibits RTK-mediated signaling.

SHP2 has also been described to regulate PI3K, Fak, RhoA, Ca2+ oscillations, Ca2+/calcineurin and NFAT signaling, and SHP2 also acts downstream of cytokine signaling in regulating Jak/Stat signaling. . In addition, SHP2 signals downstream of the immune checkpoint molecules PD-1, B- and T-lymphocyte attenuator (BTLA), and indoleamine 2,3-dioxygenase (IDO). Thus, SHP2 may have functions independent of RAS/MAPK in tumor development by modulating tumor migration, invasion, metastasis, or anti-tumor immune responses.

Worldwide, lung cancer accounts for 13% (1.6 million) of all cancer cases and 18% (1.4 million) of cancer deaths. In the United States, lung cancer causes over 160,000 deaths annually. In Western countries, 10-15% of patients with non-small cell lung cancer (NSCLC) have intratumoral activating epidermal growth factor receptor (EGFR) mutations (20,000-30,000 per year in the US). New cases), with rates as high as 30-40% reported in Asian countries. The major oncogenic EGFR mutations (L858R and ex19del) account for approximately 90% of EGFR-mutant NSCLC. This results in activation of multiple pathways that promote survival, proliferation, angiogenesis and metastasis.

Patients with EGFR-mutant NSCLC have high rates of disease control with first-generation EGFR inhibitors (eg, erlotinib, gefitinib), but resistance inevitably develops. Approximately 50% of resistant tumors have the EGFR gatekeeper T790M mutation, while the remaining 50% have various genetic alterations, often due to parallel signaling centered on SHP2 (e.g., MET , ERBB2, HGF). Furthermore, patients who develop the EGFR T790M mutation have high rates of disease control with third-generation EGFR inhibitors (eg, nazartinib and osimertinib), but also develop resistance to these agents. Resistance to these agents is poorly characterized, but in some cases has been found to be associated with the EGFR C797S mutation, which disrupts binding of third-generation EGFR inhibitors, or amplification of MET or FGFR1. . These findings underscore the persistent dependence of these cancers on RTK signaling, which should predict sensitivity to SHP2 inhibition. There are no molecularly targeted treatment options left for these patients.

Approximately 30% of NSCLC have activating KRAS mutations and these mutations are associated with resistance to EGFR TKIs. These mutations introduce amino acid substitutions at positions 12, 13, or 61, and the G12C mutation is one of the most common KRAS mutations in lung cancer, found in approximately 12% of lung adenocarcinoma. . Interestingly, EGFR and KRAS mutations are rarely detected in the same tumor, suggesting that they may play functionally equivalent roles in lung tumorigenesis. Direct inhibition of KRAS has proven challenging except for recent advances in targeting KRASG12C. Instead, inhibitors that target signaling nodes downstream of KRAS, such as RAF, MEK and ERK, have been developed and clinically tested in KRAS-mutant NSCLC, either as single agents or in combination. However, despite these efforts, no targeted therapy has been approved for patients with KRAS-mutant NSCLC.

Approximately 550,000 cases of head and neck cancer (HNSCC) are diagnosed annually worldwide. About 50,000 cases are estimated to occur annually in the United States, and about one-third of patients die within five years of diagnosis. Head and neck cancers are characterized by frequent amplification of EGFR, FGFR and their ligands, with approximately 90% having a squamous histology. Furthermore, cetuximab, a monoclonal antibody targeting EGFR, demonstrated anti-tumor efficacy in metastatic/unresectable squamous cell carcinoma of the head and neck. However, disease control with cetuximab-containing regimens has been relatively short-lived in this patient population, leaving few treatment options for this indication after progression on standard therapy. The high frequency of amplification or overexpression of RTK signaling components in HNSCC, together with preclinical data demonstrating a high proportion of HNSCC cell lines sensitive to inhibitory SHP2 inhibition, suggests that these cancers are sensitive to SHP2 inhibition. Suggest to get

Approximately 232,000 new cases of cutaneous melanoma are diagnosed worldwide each year, and its incidence has steadily increased over the decades. The MAPK pathway plays a major role in the development and progression of melanoma. BRAF mutations occur in 40-60% and NRAS mutations occur in 15-20% of melanoma patients. These mutations constitutively activate BRAF and downstream signaling in the MAPK pathway, which signals for cancer cell proliferation and survival. The third most frequently mutated gene in the MAPK pathway in melanoma is NF1, which is mutated in approximately 14% of melanomas, and more than half of these mutations can result in loss of function. is expected. NF1 mutant melanoma accounts for approximately half of BRAF and NRAS wild-type melanomas. NF1-mutant melanoma patients tend to have higher mutational burden and worse prognosis. Many of these patients respond to PD-1 inhibitors, but there is an unmet medical need for patients who are refractory to PD-1 inhibitor treatment or who relapse on PD-1 inhibitor treatment. still there.

many other metastatic/unresectable solid malignancies, such as KIT- or PDGFRA-mutant GIST, often sensitive to imatinib, K/NRAS-WT CRC, which may be sensitive to cetuximab and panitumumab; RET-, VEGFR-, and EGFR Targeting Medullary thyroid carcinoma, which is often sensitive to the TKI vandetanib, or ALK-rearranged NSCLC, which commonly responds to crizotinib or ceritinib, exhibit a dependence on RTK signaling. show. If the mechanism of resistance to such drugs were described, it would be expected that reactivation of RTK signaling would be common and predict sensitivity to SHP2 inhibition.

TNO155 is a selective, orally available, allosteric inhibitor of wild-type SHP2. TNO155 has demonstrated significant efficacy in preclinical cancer models (in vitro and in vivo). In preclinical models, susceptibility to RTK repression or inhibition predicted susceptibility to TNO155, whereas the presence of constitutive activating mutations in RAS, BRAF or PTPN11 (the gene encoding SHP2) predicted lack of susceptibility to TNO155. predicted. These observations are consistent with a role for SHP2 in RTK signaling upstream of RAS and BRAF, and biochemical evidence that TNO155 inhibits wild-type SHP2. TNO155 has demonstrated potent mitogen-activated protein kinase (MAPK) pathway pharmacodynamic regulation and anti-proliferative activity in cell lines and xenograft tumor models that depend on RTK signaling for survival and proliferation.

Nazartinib is a third generation EGFR TKI that irreversibly binds to EGFR C797 and is active against EGFR sensitizing mutations (eg ex19del, L858R) as well as the gatekeeper mutation T790M. Described resistance mechanisms for first- to third-generation EGFR TKIs include mutations that render mutant EGFR insensitive to TKIs, as well as activation of other RTK bypass pathways such as MET or HGF amplification; Mechanisms can be heterogeneous even within a given tumor. Here, the combination of TNO155 and nazartinib may prevent or delay the development of many of the described resistance mechanisms, even in the context of heterogeneity.

The combination of the present invention, TNO155 and nazartinib, is able to overcome acquired resistance to EGFR inhibitors through either secondary EGFR mutations or MET amplification. Furthermore, the combination of TNO155 and nazartinib was synergistic and consistent with sustained ERK inhibition, including but not limited to: EGFR-mutated non-small cell lung cancer (NSCLC); KRAS-mutated non-small cell lung cancer; head and neck squamous cell melanoma; gastrointestinal stromal tumor (GIST); colorectal cancer (CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC.

を有する（３Ｓ，４Ｓ）－８－（６－アミノ－５－（（２－アミノ－３－クロロピリジン－４－イル）チオ）ピラジン－２－イル）－３－メチル－２－オキサ－８－アザスピロ［４．５］デカン－４－アミン（ＴＮＯ１５５）、又はその薬学的に許容される塩；及び
（ｂ）構造：

を有する（Ｒ，Ｅ）－Ｎ－（７－クロロ－１－（１－（４－（ジメチルアミノ）ブタ－２－エノイル）アゼパン－３－イル）－１Ｈ－ベンゾ［ｄ］イミダゾール－２－イル）－２－メチルイソニコチンアミド（ナザルチニブ）、又はその薬学的に許容される塩。 The present invention provides a pharmaceutical combination comprising:
(a) structure:

(3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8 - azaspiro[4.5]decane-4-amine (TNO155), or a pharmaceutically acceptable salt thereof; and (b) structure:

(R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazole-2- yl)-2-methylisonicotinamide (nazartinib), or a pharmaceutically acceptable salt thereof.

The combination of TNO155, or a pharmaceutically acceptable salt thereof, and nazartinib, or a pharmaceutically acceptable salt thereof, will also be referred to herein as a "combination of the invention".

In another embodiment of the combination of this invention, TNO155, or a pharmaceutically acceptable salt thereof, and nazartinib, or a pharmaceutically acceptable salt thereof, are in the same formulation.

In another embodiment of the combination of this invention, TNO155 or a pharmaceutically acceptable salt thereof and nazartinib or a pharmaceutically acceptable salt thereof are in separate formulations.

In another embodiment, the combination of the invention is for simultaneous or sequential administration (in any order).

Another embodiment is a method of treating or preventing cancer in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of a combination of the invention. is.

In further embodiments of the method, the cancer is EGFR-mutated non-small cell lung cancer (NSCLC); KRAS-mutated non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; ); colon cancer (CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC.

In a further embodiment of the method, the cancer is selected from EGFR-mutant non-small cell lung cancer (NSCLC).

In further embodiments, the present invention relates to cancers such as EGFR-mutated non-small cell lung cancer (NSCLC); KRAS-mutated non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; Colon cancer (CRC); medullary thyroid cancer; and ALK-rearranged NSCLC.

In further embodiments, the present invention provides EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST) colorectal cancer (CRC); medullary thyroid cancer; and ALK-rearranged NSCLC.

Another embodiment is a pharmaceutical composition comprising the combination of the invention.

In further embodiments, the pharmaceutical composition further comprises one or more pharmaceutically acceptable excipients.

Combination dose matrix of TNO155 and nazartinib evaluating anti-proliferative effects on PC-14 and NCI-H1975 cells. Shown are the mean (n=3) percentage inhibition (compared to DMSO-treated controls) of compound-treated cells in the 6-day assay and the corresponding Loewe excess matrix. Immunoblots of the indicated proteins using lysates from PC-14 cells treated with nazartinib (0.1 or 0.3 μM), 3 μM TNO155, or a combination of nazartinib and TNO155 for 4 or 24 hours. . Results from EGFR-mutant NSCLC patients in nude mice over time after treatment with vehicle, osimertinib (10 mg/kg body weight (mpk) daily), TNO155 (10 mpk twice daily), or a combination of osimertinib and TNO155 Percentage change in tumor volume of xenografts.

The general terms used before the definitions and hereinafter preferably have the following meanings within the context of this disclosure, unless otherwise specified, and whenever used, the more general terms Independently, substituting, or remaining unchanged, more specific definitions may define more detailed embodiments of the invention.

The term "subject" or "patient" as used herein is intended to include animals suffering from or at risk of suffering from cancer or any disorder directly or indirectly associated with cancer. Examples of subjects include mammals such as humans, apes, monkeys, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non-human animals. In one embodiment, the subject is a human, eg, a human who has cancer, is at risk of having cancer, or is potentially at risk of having cancer.

As used herein, the term "treating" or "treatment" includes treatment that relieves, alleviates, or alleviates at least one symptom in a subject, or results in slowing the progression of the disease. For example, treatment can be the reduction of one or several symptoms of a disorder, such as cancer, or the complete eradication of the disorder. Within the meaning of the present disclosure, the term "treating" also prevents, delays the onset (i.e., the period prior to clinical manifestations of the disease), and/or reduces the risk of developing or exacerbating the disease. represents

The terms "including" and "including" are used herein in an open-ended and non-limiting sense, unless otherwise specified.

The terms "a", "an", and "the" and similar references in the context of describing the invention (particularly in the context of the claims below) are It should be construed to encompass both singular and plural unless otherwise indicated herein or otherwise clearly contradicted by context. Where the plural form is used for compounds, salts, etc., this is taken to mean also the single compounds, salts, etc.

As is customary in the art, dosage refers to the amount of therapeutic agent in free form. For example, if a dose of 150 mg of nazartinib is mentioned and nazartinib is used as its mesylate salt, the amount of therapeutic agent used corresponds to 150 mg of nazartinib free form.

The terms "about" and "approximately" shall generally mean an acceptable degree of error for the quantity measured given the nature or precision of the measurement. An exemplary degree of error is within 20 percent (%) of a given value or range of values, typically within 10%, more typically within 5%. In particular, when a dosage is referred to as "about" a particular value, it is intended to include ranges around ±10% of the stated value.

In particular, when a dosage is referred to as "about" a particular value, or a dosage is indicated as a particular value (i.e., the particular value is not preceded by the term "about"), it is a specified It is intended to include ranges around ±10%, or ±5% of the value of .

The term "combination therapy" or "in combination with" or "co-administration" refers to the administration of two or more therapeutic agents to treat a condition or disorder (eg, cancer) described in this disclosure. Such administration includes co-administration of these therapeutic agents at about the same time, such as in a single capsule having a fixed ratio of active ingredients. Alternatively, such administration includes multiple containers for each active ingredient, or co-administration in separate containers (eg, capsules, powders, and liquids). Powders and/or liquids may be reconstituted or diluted to the desired dose prior to administration. Moreover, such administration encompasses use of each type of therapeutic agent at about the same time or sequentially at different times. In either case, the therapeutic regimen will provide beneficial effects of the drug combination in treating the conditions or disorders described herein.

Combination therapy provides a "synergistic effect" and is "synergistic," i.e., the effect obtained when the active ingredients are used together is greater than the sum of the effects obtained from using the compounds separately. It can show big. Synergism occurs when the active ingredients are (1) formulated and administered at the same time, or delivered at the same time in a combined unit dosage form; (2) delivered alternately or in parallel as separate formulations. or (3) when delivered by some other regimen. When delivered in alternating therapy, a synergistic effect can be obtained when the compounds are administered or delivered sequentially, eg, by different injections in separate syringes. In general, during alternation therapy, effective doses of each active ingredient are administered sequentially, i.e., sequentially, whereas in combination therapy, effective doses of two or more active ingredients are administered together. be done.

The term "pharmaceutical combination" as used herein refers to either a fixed combination in one dosage unit form or a kit of parts for non-fixed combination or combined administration, wherein two or more The therapeutic agents may be administered independently at the same time or separately within time intervals, in particular these time intervals allow the combination partners to exhibit a synergistic effect, eg a synergistic effect.

As used herein, the term "synergistic effect" refers to the effect of two therapeutic agents, e.g., the compound TNO155 as a SHP2 inhibitor and nazartinib as an EGFR inhibitor, on a proliferative disease, particularly cancer, or a disease thereof. It refers to an action that slows the symptomatic progression of symptoms and produces an effect that is greater than the simple addition of the effects of each drug administered by itself. Synergism can be determined, for example, by a suitable method, such as the Sigmoid-Emax formula (Holford, NHG and Scheiner, LB, Clin. Pharmacokinet. 6:429-453 (1981)), Loewe additivity Formula (Loewe, S. and Muischnek, H., Arch. Exp. Pathol Pharmacol. 114:313-326 (1926)) and median-effect formula (Chou, TC and Talalay, P., Adv. Enzyme Regul.22:27-55 (1984)). Each of the formulas referred to above can be used on experimental data to generate corresponding graphs to help assess the effects of drug combinations. The corresponding graphs associated with the formulas referred to above are concentration-effect curves, isobologram curves, and combination index curves, respectively.

The combination of the invention, TNO155 and nazartinib, is also intended to represent unlabeled as well as isotopically labeled forms of the compounds. An isotopically-labeled compound has one or more atoms replaced by an atom having a selected atomic mass or mass number. Examples of isotopes that can be incorporated into TNO155 and nazartinib include isotopes of hydrogen, carbon, nitrogen, oxygen, and chlorine, such as ² H, ³ H, ¹¹ C, ¹³ C, ¹⁴ C, ¹⁵ N, ³⁵ S, ³⁶ Cl. The invention includes isotopically labeled TNO155 and nazartinib, eg, in which radioactive isotopes such as ³ H and ¹⁴ C or non-radioactive isotopes such as ² H and ¹³ C are present. Isotopically labeled TNO155 and nazartinib can be used in metabolic studies (by ¹⁴ C), kinetic studies (eg by ² H or ³ H), detection or imaging techniques such as positron emission tomography (PET) or single photon emission computed tomography. It is useful in imaging (SPECT), including drug or substrate tissue distribution assays, or in radiotherapy of patients. In particular, ¹⁸ F-labeled LSZ102 may be particularly desirable for PET or SPECT studies. Isotopically-labeled compounds of the present invention are generally labeled by conventional techniques known to those skilled in the art, or by processes analogous to those described in the accompanying Examples using appropriate isotopically-labeled reagents. can be prepared.

Furthermore, substitution with heavier isotopes, particularly deuterium (i.e., ² H or D), may provide certain therapeutic advantages due to greater metabolic stability, such as increased in vivo half-life, reduced dosage requirements, or may result in an improved therapeutic index. It is understood that deuterium is considered a substituent of TNO155 or nazartinib in this context. The concentration of such heavier isotopes, specifically deuterium, may be defined by an isotopic enrichment factor. As used herein, the term "isotopic enrichment factor" refers to the ratio between the abundance of an isotope and the natural abundance of a specified isotope. If a substituent in TNO155 or nazartinib is designated as deuterium, then such compounds have an isotopic enrichment factor of at least 3500 for each deuterium atom specified (at each deuterium atom specified 52.5% deuterium incorporation), at least 4000 (60% deuterium incorporation), at least 4500 (67.5% deuterium incorporation), at least 5000 (75% deuterium incorporation), at least 5500 (82.5% deuterium incorporation). 5% deuterium incorporation), at least 6000 (90% deuterium incorporation), at least 6333.3 (95% deuterium incorporation), at least 6466.7 (97% deuterium incorporation), at least 6600 (99% deuterium incorporation), or at least 6633.3 (99.5% deuterium incorporation).

DESCRIPTION OF THE PREFERRED EMBODIMENTS TNO155 is an investigational drug that is an orally available small molecule inhibitor of SHP2 activity. SHP2 signals downstream of activated RTKs. In preclinical models, tumor dependence on RTKs predicts dependence on SHP2.

In one embodiment, a method of treating cancer, wherein a subject in need thereof comprises (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridine-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, as a second therapeutic agent A method comprising administering a pharmaceutical composition comprising the combination.

In further embodiments, the cancer is EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); Colorectal cancer (CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC.

In a further embodiment, the cancer is in advanced or metastatic stage.

In a further embodiment, the subject has an activating EGFR mutation, has progressed on a standard of care (SOC) EGFR tyrosine kinase inhibitor (TKI) (or has no available SOC EGFR TKI), and is on platinum or advanced NSCLC with a KRAS G12 mutation that progressed with SOC; or advanced HNSCC that progressed with platinum-containing combination chemotherapy; or advanced esophageal SCC that progressed with platinum-containing chemotherapy; or active Advanced CRC lacking KRAS (except KRAS G12C), NRAS, or BRAF mutations and progressed on fluoropyrimidines, oxaliplatin, and irinotecan; or advanced NRAS/BRAF WT cutaneous melanoma progressed on SOC; or progressed on SOC Patients with any of the following advanced GIST.

In further embodiments, the subject is a patient with one or more of the following cancers:
a. Advanced NSCLC with EGFR TKI-sensitizing EGFR mutations (eg exon 19 deletion, L858R) after progression on osimertinib or nazartinib.
b. Having an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) after progression on first- and/or second-generation EGFR TKIs (e.g., erlotinib, gefitinib, afatinib); Advanced NSCLC demonstrated to lack the T790 mutation after progression of .
c. Has an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) and has progressed on osimertinib as most recent therapy (continued osimertinib treatment until 2 weeks prior to starting study treatment). advanced NSCLC (so osimertinib can be continued during the screening period), or such patients who have recently discontinued osimertinib.

In further embodiments, the cancer is EGFR-mutant non-small cell lung cancer (NSCLC).

In further embodiments, the subject is a patient with one or more of the following cancers:
a. Advanced NSCLC with EGFR TKI-sensitizing EGFR mutations (eg exon 19 deletion, L858R) after progression on osimertinib or nazartinib.
b. Having an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) after progression on first- and/or second-generation EGFR TKIs (e.g., erlotinib, gefitinib, afatinib); Advanced NSCLC demonstrated to lack the T790 mutation after progression of .
c. Has an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) and has progressed on osimertinib as most recent therapy (continued osimertinib treatment until 2 weeks prior to starting study treatment). advanced NSCLC (so osimertinib can be continued during the screening period), or such patients who have recently discontinued osimertinib.

In further embodiments, the cancer is head and neck squamous cell carcinoma.

In further embodiments, the cancer is KRAS-mutant non-small cell lung cancer.

In further embodiments, the cancer is head and neck squamous cell carcinoma (HNSCC).

In further embodiments, the cancer is melanoma.

In further embodiments, the cancer is gastrointestinal stromal tumor (GIST).

In a further embodiment, the cancer is colon cancer (CRC).

In a further embodiment, the cancer is medullary thyroid cancer.

In further embodiments, the cancer is ALK-rearranged NSCLC.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and the second therapeutic agent are administered simultaneously, separately, or over time.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazine administered to a subject in need thereof -2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and the second therapeutic agent effective in treating

In further embodiments, the second therapeutic agent is an EGFR inhibitor.

In further embodiments, the second therapeutic agent is osimertinib, or a pharmaceutically acceptable salt thereof.

In a further embodiment, osimertinib is administered orally at a dose ranging from about 40 mg to about 80 mg/day, with or without food.

In a further embodiment, osimertinib is administered orally at a dose of 80 mg/day with or without food.

In a further embodiment, the EGFR inhibitor is (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H -benzo[d]imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine is from about 1.5 mg/day to about 100 mg/day, such as from about 1.5 mg/day to about 60 mg/day or from about 20 mg/day to about It is administered orally at doses ranging from 60 mg/day.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine is about 1.5 mg/day, or 3 mg/day, or 6 mg/day, or 10 mg/day, or 20 mg/day, or 30 mg/day; or 40 mg/day, or 50 mg/day, or 60 mg/day, or 70 mg/day, or 80 mg/day, or 90 mg/day, or 100 mg/day.

In a further embodiment, the dose (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl- 2-oxa-8-azaspiro[4.5]decan-4-amine is administered in cycles of 2 weeks off followed by 1 week off. Here, in a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3- Methyl-2-oxa-8-azaspiro[4.5]decan-4-amine at 20 mg, 30 mg, 40 mg, 60 mg, 80 mg or 100 mg in 21-day cycles of 2 weeks on followed by 1 week off is administered orally at a daily dose of

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] Imidazol-2-yl)-2-methylisonicotinamide is administered orally at doses ranging from about 75 mg/day to 350 mg/day.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] imidazol-2-yl)-2-methylisonicotinamide is about 75 mg/day, or 100 mg/day, or 150 mg/day, or 200 mg/day, or 250 mg/day, or 300 mg/day, or 350 mg/day The dose is administered orally.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] Imidazol-2-yl)-2-methylisonicotinamide is administered orally at 150 mg/day.

In another embodiment, a method of treating cancer, comprising administering to a patient in need thereof about 1.5 mg/day, or 3 mg/day, or 6 mg/day, or 10 mg/day, or 20 mg/day; or 30 mg/day, or 40 mg/day, or 50 mg/day, or 60 mg/day, or 70 mg/day, or 80 mg/day, or 90 mg/day, or 100 mg/day, orally administered (3S, 4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro [4. 5] A method comprising administering decane-4-amine.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 - oxa-8-azaspiro[4.5]decan-4-amine orally at daily doses of 20 mg, 30, 40, or 60 mg in 21-day cycles of 2 weeks on and then 1 week off administered.

In further embodiments, the cancer is EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); Colorectal cancer (CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC.

In further embodiments, the cancer is EGFR-mutant non-small cell lung cancer (NSCLC).

In further embodiments, the cancer is head and neck squamous cell carcinoma.

In further embodiments, the cancer is KRAS-mutant non-small cell lung cancer.

In further embodiments, the cancer is head and neck squamous cell carcinoma (HNSCC).

In further embodiments, the cancer is melanoma.

In further embodiments, the cancer is gastrointestinal stromal tumor (GIST).

In a further embodiment, the cancer is colon cancer (CRC).

In a further embodiment, the cancer is medullary thyroid cancer.

In further embodiments, the cancer is ALK-rearranged NSCLC.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and the second therapeutic agent are administered simultaneously, separately, or over time.

In further embodiments, the second therapeutic agent is an EGFR inhibitor.

In further embodiments, the second therapeutic agent is osimertinib, or a pharmaceutically acceptable salt thereof.

In a further embodiment, the EGFR inhibitor is (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H -benzo[d]imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] imidazol-2-yl)-2-methylisonicotinamide is about 75 mg/day, or 100 mg/day, or 150 mg/day, or 200 mg/day, or 250 mg/day, or 300 mg/day, or 350 mg/day The dose is administered orally.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] Imidazol-2-yl)-2-methylisonicotinamide is administered orally at 150 mg/day.

In one embodiment, for the pharmaceutical combination of the invention, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl) -3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and 7(R,E)-N-(7-chloro-1- (1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable A pharmaceutical combination comprising a salt of

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E)-N-(7-chloro-1-(1-(4-( dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, separately They may be administered simultaneously or sequentially in any order.

In a further embodiment the pharmaceutical combination is for oral administration.

In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine is an oral dosage form (hard shell gelatin capsules in dose strengths of 1.5 mg, 5 mg, 10 mg and 50 mg).

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] Imidazol-2-yl)-2-methylisonicotinamide is an oral dosage form (hard shell gelatin capsules in dose strengths of 25 mg or 50 mg).

In another embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E)-N-(7-chloro-1-(1-(4-( A pharmaceutical combination of dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, and A pharmaceutical composition comprising at least one pharmaceutically acceptable carrier.

In further embodiments, EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl) for use in the treatment of medullary thyroid cancer; and ALK-rearranged NSCLC ) thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E)-N -(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl)-2-methylisonicotinamide , or a pharmaceutical combination of a pharmaceutically acceptable salt thereof.

In another embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridine-) for use in treating EGFR-mutant non-small cell lung cancer (NSCLC). 4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E )-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl)-2-methyl A pharmaceutical combination of isonicotinamide, or a pharmaceutically acceptable salt thereof.

In another embodiment, EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); ((3S,4S)-8-(6-amino-5-((2-amino -3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof , and (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazole-2- yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof.

In another embodiment, EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC; (2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or its pharmaceutically acceptable salts and (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] A pharmaceutical combination of imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, or (3S,4S)-8-(6-amino-5-((2-amino-3 -chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) - administering a pharmaceutical composition comprising a pharmaceutical combination of 2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier.

In another embodiment, EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC; (2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or its pharmaceutically acceptable salts and (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] A pharmaceutical combination of imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, or (3S,4S)-8-(6-amino-5-((2-amino-3 -chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decane-4-amine, or a pharmaceutically acceptable salt thereof, and (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) - administering a pharmaceutical composition comprising a pharmaceutical combination of 2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier.

In another embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2 -oxa-8-azaspiro[4.5]decan-4-amine is about 1.5 mg/day, or 3 mg/day, or 6 mg/day, or 10 mg/day, or 20 mg/day, or 30 mg/day; or orally at doses of 40 mg/day, or 50 mg/day, or 60 mg/day.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] imidazol-2-yl)-2-methylisonicotinamide is about 75 mg/day, or 100 mg/day, or 150 mg/day, or 200 mg/day, or 250 mg/day, or 300 mg/day, or 350 mg/day The dose is administered orally.

In a further embodiment, (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] Imidazol-2-yl)-2-methylisonicotinamide is administered orally continuously at a dose of about 150 mg/day.

Pharmacology and Usefulness Non-Small Cell Lung Cancer—In 2012, it was estimated that approximately 1.8 million people were diagnosed with lung cancer worldwide and 1.6 million died of lung cancer. Non-small cell lung cancer accounts for approximately 85% of lung cancers, with adenocarcinoma and squamous cell carcinoma being the most common subtypes. Standard treatment for advanced-stage non-small cell lung cancer (NSCLC) without genetic mutations in druggable driver oncogenes such as EGFR, ALK, or ROS is chemotherapy and immunotherapy, administered simultaneously or sequentially. Including therapy. Although these treatments offer clinical benefits, the majority of patients exhibit disease progression within one year, and the prognosis of patients with advanced NSCLC remains poor. Immunotherapy for NSCLC with immune checkpoint inhibitors has demonstrated promise, but some NSCLC patients receive sustained disease control for years. However, such long-term non-progressors are rare and there is an urgent need for combination therapies that can increase the proportion of patients who respond to immunotherapy with checkpoint inhibitors and remain in remission. there is Activating mutations in the KRAS oncogene occur in approximately 30% of lung adenocarcinoma and have been associated with poor outcome in several studies. As there are no approved drugs that directly target mutant KRAS, the standard of care for advanced-stage KRAS-mutant NSCLC is also the chemotherapy and immunotherapy described above.

Approximately 232,000 new cases of cutaneous melanoma are diagnosed worldwide each year, and its incidence has steadily increased over the decades. The MAPK pathway plays a major role in the development and progression of melanoma. BRAF mutations occur in 40-60% and NRAS mutations occur in 15-20% of melanoma patients. These mutations constitutively activate BRAF and downstream signaling in the MAPK pathway, which signals for cancer cell proliferation and survival.

The third most frequently mutated gene in the MAPK pathway in melanoma is NF1, which is mutated in approximately 14% of melanomas, and more than half of these mutations can result in loss of function. is expected. NF1 mutant melanoma accounts for approximately half of BRAF and NRAS wild-type melanomas. NF1-mutant melanoma patients tend to have higher mutational burden and worse prognosis. Many of these patients respond to PD-1 inhibitors, but there is an unmet medical need for patients who are refractory to PD-1 inhibitor treatment or who relapse on PD-1 inhibitor treatment. still there.

TNO155 is a first-in-class allosteric inhibitor of wild-type SHP2. SHP2 is a ubiquitously expressed non-receptor protein tyrosine phosphatase (PTP) composed of two N-terminal SH2 domains, a classical PTP domain and a C-terminal tail. Phosphatase activity is autoinhibited by two SHP2 domains that bind to the PTP domain (closed conformation). Upon receptor tyrosine kinase (RTK) activation, SHP2 is recruited to the plasma membrane, where it binds to the activated RTK and several adapter proteins to signal by activating the RAS/MAPK pathway. Relay transmission. TNO155 binds to the inactive or 'closed' conformation of SHP2, thereby preventing it from opening to the active conformation. This prevents signaling from the activated RTK to the downstream RAS/MAPK pathway.

TNO155 has demonstrated efficacy in a wide range of RTK-dependent human cancer cell lines and in vivo xenografts. Preclinical in vitro and in vivo evaluation of TNO155 has been performed in RTK-dependent human cancer models such as EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); gastrointestinal stromal tumor (GIST); colorectal cancer (CRC); medullary thyroid carcinoma; and ALK-rearranged NSCLC. SHP2 inhibition was measured by assessing biomarkers within the MAPK signaling pathway, such as decreased levels of phosphorylated ERK1/2 (pERK) and downregulation of dual specificity phosphatase 6 (DUSP6) mRNA transcripts. obtain. In KYSE-520 (esophageal squamous cell carcinoma) and DETROIT-562 (pharyngeal squamous cell carcinoma) cancer cell lines, the in vitro pERK IC50 was 8 nM (3.4 ng/mL) and 35 nM (14.8 ng/mL), respectively. with antiproliferative IC50s of 100 nM (42.2 ng/mL) and 470 nM (198.3 ng/mL), respectively. The anti-proliferative effects of TNO155 were shown to be most effective in cancer cell lines dependent on RTK signaling. In vivo, SHP2 inhibition by orally administered TNO155 (20 mg/kg) reduced DUSP6 mRNA transcripts by approximately 95% in the EGFR-dependent DETROIT-562 cancer cell line when administered on a twice-daily schedule. , and achieved a regression of 47%. Dose fractionation studies have shown that maximal efficacy is achieved when 50% PD inhibition is achieved in at least 80% of the dosing intervals in combination with modulation of the tumor DUSP6 biomarker. show.

Epidermal growth factor receptor (EGFR) is an important therapeutic target that has been established in NSCLC with activating EGFR mutations. Numerous trials with first-generation (e.g., erlotinib, gefitinib) and second-generation (e.g., afatinib, dacomitinib) EGFR inhibitors have been conducted in the EGFR-mutant advanced/unresectable NSCLC population, and chemotherapy has been performed in this population. We have consistently demonstrated superior efficacy of EGFR tyrosine kinase inhibitors (TKIs) over therapy. Resistance to first-generation EGFR TKIs was shown to occur through the development of the EGFR "gatekeeper" T790M mutation, which impairs TKI binding, and through activation of alternative RTK pathways, including MET and ERBB2 amplification. Clinical trials with third-generation irreversible EGFR inhibitors (e.g., osimertinib, rociletinib) that inhibit EGFR activation and gatekeeper mutations have demonstrated efficacy in EGFR T790M mutant NSCLC, which highlights their persistent dependence on EGFR signaling. Emerging data from cancers that have become resistant to third-generation inhibitors suggest that these cancers continue to select for activating RTK signaling, leading to resistance mutations in EGFR (C797S). Mutations as well as RTK amplifications (MET, ERBB2, FGFR1) have been described. Limited treatment options are available for cancer patients who have developed resistance to first/second and third generation EGFR TKIs. Since SHP2 carries out EGFR signaling and preclinical models have demonstrated a strong correlation between RTK and SHP2 dependence, TNO155 suggested that resistance was caused by either EGFR or signaling from another RTK. It is expected to offer clinical benefit in these cancers regardless of whether they are

Over 90% of head and neck cancers are characterized by overexpression or amplification of EGFR; amplification/overexpression of other RTKs, particularly FGFR, and their ligands are common. Inhibition of EGFR by cetuximab in advanced HNSCC also demonstrated clinical benefit, although disease control was not durable. The low efficacy of EGFR inhibition in HNSCC may be related to compensatory signaling through other RTKs, which would be expected to be abrogated by SHP2 inhibition by TNO155 treatment. Furthermore, preclinical studies have identified head and neck cancer cells as the lineage with the highest frequency of susceptibility to SHP2 inhibition.

Patients with metastatic or unresectable RTK-driven cancers, such as anaplastic lymphoma kinase (ALK)-rearranged NSCLC or stem cell factor receptor (KIT)-mutant gastrointestinal stromal tumors (GIST), may benefit from these RTKs directly. While benefiting from targeting molecules, resistance to these agents always occurs. Mechanisms of resistance often involve drug resistance mutations in targeted RTKs and/or activation of bypass RTK pathways; further therapeutic options are often limited. Targeting SHP2 via TNO155 is a logical approach in such RTK-dependent cancers.

Nazartinib Selectively Inhibits EGFR Activating (L858R, Exon 19 Deletion (ex19del)) and T790M Resistance Mutations of EGFR While Permitting Wild-Type (WT) EGFR Targeted Covalent Epithelium It is a growth factor receptor (EGFR) inhibitor. Nazartinib has been tested in seven clinical trials. In a first-in-human trial of nazartinib in patients with EGFR-mutant NSCLC, the recommended phase II dose of single-agent nazartinib was determined to be 150 mg QD (7 dose levels were tested from 75 mg to 350 mg QD (maximum tolerated dose has not been established and anti-tumor efficacy was observed at all doses). Promising anti-tumor activity of nazartinib was demonstrated in both pre-treatment and treatment-naive patients with advanced EGFR-mutant NSCLC.

Patients with EGFR-mutant NSCLC have high rates of disease control with EGFR inhibitors (eg, erlotinib, gefitinib, osimertinib), but resistance inevitably develops. Resistance mechanisms are heterogeneous, but generally result in restoration of mutant EGFR signaling and/or amplification or overexpression of RTKs other than EGFR, such as MET, or their ligands. Since SHP2 inhibition impairs signaling through multiple RTKs, the combination of TNO155 and nazartinib could be used to inhibit the initiation of driver oncogenic EGFR mutations present in all tumor cells, while maintaining It has the potential to block multiple heterogeneous resistance mechanisms that can occur in different clones. Nazartinib was selected for combination with TNO155 because it is not associated with adverse events of decreased left ventricular ejection fraction. Such events have been described for osimertinib, another 3rd generation EGFR TKI (Tagrisso® prescribing information).

The preclinical data presented in the Examples below provide in vitro and in vivo evidence that the combination of SHP2 inhibitor, TNO155 and EGFR inhibitor, nazartinib exerts significant combined effects.

Thus, the combination therapy of the present invention provides particular benefits, e.g., combined efficacy, tolerability, e.g., reduced side effects (e.g., reduced cutaneous toxicity and/or cardiomyopathy), NSCLC, e.g.: active NSCLC with EGFR mutations, progressed on standard of care (SOC) EGFR tyrosine kinase inhibitors (TKIs) (or no SOC EGFR TKIs available), and progressed on platinum-containing combination chemotherapy (e.g. advanced NSCLC); or NSCLC with a KRAS G12 mutation that progressed with SOC (e.g., advanced NSCLC); or HNSCC that progressed on platinum-containing combination chemotherapy; :
a. NSCLC with EGFR TKI-sensitizing EGFR mutations (eg exon 19 deletion, L858R) after progression on osimertinib or nazartinib (eg advanced NSCLC).
b. Having an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) after progression on first- and/or second-generation EGFR TKIs (e.g., erlotinib, gefitinib, afatinib); NSCLC demonstrated to lack the T790 mutation (eg, advanced NSCLC) after progression of .
c. Has an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) and has progressed on osimertinib as most recent therapy (continued osimertinib treatment until 2 weeks prior to starting study treatment). NSCLC (e.g. advanced NSCLC) (so osimertinib can be continued during the screening period) or patients who recently discontinued osimertinib.

Pharmaceutical Compositions In another aspect, the invention provides therapeutically effective amounts of TNO155 and nazartinib formulated together with one or more pharmaceutically acceptable carriers (additives) and/or diluents. A pharmaceutically acceptable composition is provided comprising: As described in detail below, the pharmaceutical compositions of the invention may be specially formulated for administration in solid or liquid form, and are adapted for oral administration, e.g. aqueous or non-aqueous solutions or suspensions), tablets such as those intended for buccal, sublingual and systemic absorption, boluses, powders, granules, pastes for application to the tongue.

The phrase "therapeutically effective amount" as used herein means a more or less desired amount in at least a subpopulation of cells in an animal at a reasonable benefit/risk ratio applicable to any medical treatment. means an amount of a compound, material, or composition, including a compound of the invention, effective to produce a therapeutic effect of.

The phrase "pharmaceutically acceptable" is defined as the use of sound medical judgment, without undue toxicity, irritation, allergic reactions, other problems or complications, commensurate with a reasonable benefit/risk ratio. In scope, it is used herein to refer to compounds, materials, compositions, and/or dosage forms suitable for use in contact with human and animal tissue.

As used herein, the phrase "pharmaceutically acceptable carrier" refers to a pharmaceutically acceptable material, composition, or vehicle such as liquid or solid fillers, diluents, excipients, manufacturing aids. agents (e.g., lubricants, talc, magnesium stearate, calcium stearate, or zinc stearate, or stearic acid), or from one organ or body part to another organ or body part means a solvent encapsulating material involved in the transport or transport of the subject compound. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient. Some examples of materials that may be provided as pharmaceutically acceptable carriers are: (1) sugars such as lactose, glucose and sucrose; (2) starches such as corn starch and potato starch; (3) cellulose. (4) powdered gum tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients such as cocoa butter and suppository waxes. (9) oils such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil, and soybean oil; (10) glycols such as propylene glycol; (11) polyols such as glycerin, sorbitol, mannitol, and (12) esters such as ethyl oleate and ethyl laurate; (13) agar; (14) buffers such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19) ethyl alcohol; (20) pH buffers; (21) polyesters, polycarbonates, and/or polyanhydrides; Other non-toxic compatible substances are listed.

As set forth above, certain embodiments of the present compounds may contain basic functional groups such as amino or alkylamino groups, and thus pharmaceutically acceptable salts are can be formed by any legally acceptable acid. The term "pharmaceutically acceptable salts" in this regard refers to the relatively non-toxic, inorganic and organic acid addition salts of compounds of the present invention. The salts are thus formed in the administration vehicle or in the dosage form manufacturing process or by separately reacting the purified compound of the invention, in its free base form, with a suitable organic or inorganic acid. Salts can be prepared in situ by isolation during subsequent purification. Representative salts include hydrobromide, hydrochloride, sulfate, bisulfate, phosphate, nitrate, acetate, valerate, oleate, palmitate, stearate, laurate. , benzoate, lactate, phosphate, tosylate, citrate, maleate, fumarate, succinate, tartrate, napthylate, mesylate, glucoheptonate, lactobionate, laurylsulfonate and the like (see, for example, Berge et al. (1977) "Pharmaceutical Salts", J. Pharm. Sci. 66: 1-19).

Pharmaceutically acceptable salts of the subject compounds include conventional non-toxic salts of the compounds, eg, derived from non-toxic organic or inorganic acids, or quaternary ammonium salts. For example, such conventional non-toxic salts include those derived from inorganic acids such as hydrochloric acid, hydrobromic acid, sulfuric acid, sulfamic acid, phosphoric acid, nitric acid, etc.; and organic acids such as acetic acid, propionic acid, succinic acid. acid, glycolic acid, stearic acid, lactic acid, malic acid, tartaric acid, citric acid, ascorbic acid, palmitic acid, maleic acid, hydroxymaleic acid, phenylacetic acid, glutamic acid, benzoic acid, salicylic acid, sulfanilic acid, 2-acetoxybenzoic acid, Examples include salts prepared from fumaric acid, toluenesulfonic acid, methanesulfonic acid, ethanedisulfonic acid, oxalic acid, isethionic acid, and the like. For example, a pharmaceutically acceptable salt of TNO155 is the succinate. A pharmaceutically acceptable salt of nazartinib is, for example, the mesylate.

In other cases, the compounds of the invention may contain one or more acidic functional groups, and thus pharmaceutically acceptable salts may be formed with pharmaceutically acceptable bases. can. The term "pharmaceutically acceptable salts" as used herein refers to the relatively non-toxic, inorganic and organic base addition salts of the compounds of the present invention. The salt may also be added in an administration vehicle or in a dosage form manufacturing process, or the purified compound, in its free acid form, to a suitable base, such as a pharmaceutically acceptable hydroxide of a metal cation. , carbonate, or bicarbonate, and ammonia, or a pharmaceutically acceptable organic primary, secondary, or tertiary amine. Representative alkali or alkaline earth salts include lithium, sodium, potassium, calcium, magnesium and aluminum salts and the like. Representative organic amines useful in forming base addition salts include ethylamine, diethylamine, ethylenediamine, ethanolamine, diethanolamine, piperazine, and the like (see, eg, Berge et al., supra).

Wetting agents, emulsifying agents and lubricants such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, exfoliating agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the composition. may exist in

Examples of pharmaceutically acceptable antioxidants include: (1) water-soluble antioxidants such as ascorbic acid, cysteine hydrochloride, sodium hydrogen sulfide, sodium metabisulfite, sodium sulfite, etc.; 2) oil-soluble antioxidants such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, etc.; and (3) metal chelating agents such as Citric acid, ethylenediaminetetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid and the like.

Formulations of the present invention include those suitable for oral, nasal, topical (including buccal and sublingual), rectal, vaginal, and/or parenteral administration. The formulations may conveniently be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy. The amount of active ingredient that can be combined with the carrier materials to produce a single dosage form will vary depending upon the host being treated, the particular mode of administration. The amount of active ingredient that can be combined with the carrier materials to produce a single dosage form will generally be that amount of the compound that produces a therapeutic effect. Generally, out of 100 percent, this amount will range from about 0.1 percent to about 99 percent, preferably from about 5 percent to about 70 percent, and most preferably from about 10 percent to about 30 percent of active ingredient.

In certain embodiments, the formulations of the present invention comprise excipients selected from the group consisting of cyclodextrins, celluloses, liposomes, micelle-forming agents such as bile acids, and polymeric carriers such as polyesters and polyanhydrides; Including compounds of the invention. In certain embodiments, the formulations described above render the compounds of the invention orally bioavailable.

Methods of preparing this formulation or composition include the step of bringing into association a compound of the present invention with the carrier and, optionally, one or more accessory ingredients. In general, the formulations are prepared by uniformly and intimately bringing into association a compound of the invention with liquid carriers or finely divided solid carriers or both, and then, if necessary, shaping the product. prepared.

Compositions of the invention suitable for oral administration may be in the form of capsules, cachets, pills, tablets, lozenges (flavored bases, usually with sucrose and gum arabic or gum tragacanth), powders, granules. as a solution, suspension, or solid dispersion in an aqueous or non-aqueous liquid; as an oil-in-water or water-in-oil liquid emulsion; or as an elixir or syrup. or as a lozenge (using an inert base such as gelatin and glycerin, or sucrose and gum arabic), mouthwash, etc., each containing a predetermined amount of a compound of the invention. Contains as an active ingredient. A compound of the present invention may also be administered as a bolus, electuary, or paste.

In solid dosage forms of the present invention (capsules, tablets, pills, dragees, powders, granules, troches, etc.) for oral administration, the active ingredient is combined with one or more pharmaceutically acceptable carriers, e.g. sodium phosphate or dicalcium phosphate, and/or mixed with any of the following: (1) fillers or bulking agents such as starch, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binding (3) wetting agents such as glycerol; (4) disintegrating agents such as agar, calcium carbonate, potato or tapioca starch, alginic acid; certain silicates, and sodium carbonate; (5) solution retarding agents such as paraffin; (6) absorption enhancers such as quaternary ammonium compounds and surfactants such as poloxomers and sodium lauryl sulfate; (8) Absorbents such as kaolin and bentonite clays; (9) Lubricants such as talc, calcium stearate, magnesium stearate. , solid polyethylene glycol, sodium lauryl sulfate, zinc stearate, sodium stearate, stearic acid, and mixtures thereof; (10) colorants; and (11) controlled release agents such as crospovidone or ethylcellulose. For capsules, tablets, and pills, the pharmaceutical composition may also include buffering agents. Solid compositions of a similar type may also be used as fillers in soft and hard shell gelatin capsules using such excipients as lactose or milk sugar, high molecular weight polyethylene glycols and the like.

A tablet may be made by compression or molding, optionally with one or more accessory ingredients. using binders (e.g. gelatin or hydroxypropyl methylcellulose), lubricants, inert diluents, preservatives, disintegrants (e.g. sodium starch glycolate or cross-linked sodium carboxymethylcellulose), surfactants, or dispersing agents; Compressed tablets may be prepared. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

Tablets and other solid dosage forms, such as dragees, capsules, pills, and granules, of the pharmaceutical compositions of the present invention are optionally coated with coatings and shells such as enteric coatings and other coatings well known in the pharmaceutical formulating art. may be scored or prepared by Also, for example, hydroxypropylmethylcellulose, other polymer matrices, liposomes, and/or microspheres may be used in varying proportions to achieve the desired release profile to achieve sustained or controlled release of the active ingredient. may be formulated in It may be formulated for rapid release, eg, lyophilized. Sterilized, for example, by filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved in sterile water, or some other sterile injectable medium immediately prior to use. good too. The compositions may also optionally contain opacifying agents and may be of a composition that they release the active ingredient(s) only, or preferentially, optionally in a delayed manner, in some part of the gastrointestinal tract. . Examples of embedding compositions that can be used include polymeric substances and waxes. The active ingredient can also be in micro-encapsulated form, if appropriate, with one or more of the above-described excipients.

Liquid dosage forms for oral administration of the compounds of the invention include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient, liquid dosage forms may contain inert diluents commonly used in the art such as water or other solvents, solubilizers and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate. , ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (especially cottonseed, peanut, corn, germ, olive, castor, and sesame), glycerol, tetrahydrofuryl alcohol , polyethylene glycol, and fatty acid esters of sorbitan, and mixtures thereof.

Besides inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preserving agents.

Suspensions contain, in addition to the active compound, suspending agents such as ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar and gum tragacanth. may contain a mixture of

Examples of suitable aqueous and non-aqueous carriers that may be used in pharmaceutical compositions of the present invention include water, ethanol, polyols (eg, glycerol, propylene glycol, polyethylene glycol, etc.), and suitable mixtures thereof. , vegetable oils such as olive oil, and injectable organic esters such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials such as lecithin, by maintenance of the required particle size in the case of dispersions, and by the use of surfactants.

The compositions may also contain adjuvants such as preserving, wetting, emulsifying, and dispersing agents. Prevention of the action of microorganisms on the subject compounds may be ensured by the inclusion of various antibacterial and antifungal agents such as parabens, chlorobutanol, phenol sorbic acid. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions.

When the compounds of the present invention are administered to humans and animals as pharmaceuticals, they may be given per se or in combination with pharmaceutically acceptable carriers, for example 0.1-99% (more preferably 10-30%) of active ingredient.

Compounds of the invention (which may be used in a suitable hydrated form), and/or pharmaceutical compositions of the invention may be formulated into pharmaceutically acceptable formulations by conventional methods known to those of ordinary skill in the art. Formulated.

The actual dosage level of the active ingredients in the pharmaceutical compositions of the invention will be effective for a particular patient, composition and mode of administration to achieve the desired therapeutic response without being toxic to the patient. The amount of active ingredient may be varied to achieve.

The selected dosage level will depend on the activity of the particular compound of the invention, or ester, salt, or amide thereof, used, the route of administration, the time of administration, the rate of excretion or metabolism of the particular compound to be used. , rate and extent of absorption, duration of treatment, other drugs, compounds, and/or materials used in combination with the particular compound used, age, sex, weight, symptoms of the patient to be treated, It will depend on a variety of factors, including health status and previous medical history, as well as factors as is well known in the medical arts.

A physician or veterinarian having ordinary skill in the art can readily determine and prescribe the effective amount of the pharmaceutical composition required. For example, a physician or veterinarian may administer a pharmaceutical composition at a level lower than that required to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved. The dose of the compound of the invention used in the product could be started.

In general, a suitable daily dose of a combination of the invention will be that amount of each compound which is the lowest dose effective to produce a therapeutic effect. Such effective amounts will generally depend on the factors previously described.

In another aspect, the present invention provides a therapeutically effective amount, as described above, formulated with one or more pharmaceutically acceptable carriers (additives) and/or diluents. Pharmaceutically acceptable compositions comprising one or more compounds of interest are provided.

TNO155 and nazartinib (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa- 8-Azaspiro[4.5]decane-4-amine (TNO155) is synthesized according to Example 69 of WO2015/107495, respectively. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) -2-methylisonicotinamide (nazartinib) is synthesized according to Example 5 of WO2013/184757.

The utility of TNO155 and nazartinib as described herein can be demonstrated by testing in the Examples below.

Example 1
Combinatorial Synergy in TNO155 and Nazartinib in EGFR Mutant NSCLC Cell Lines Human cancer cell lines derived from CCLE (Cancer Cell Line Encyclopedia) were demonstrated by single nucleotide polymorphism analysis when CCLE was established in 2012, They were tested for mycoplasma infection using PCR-based detection technology (IDEXX BioAnalytics). All cell lines used were thawed directly from CCLE collection stocks. All cell lines were transformed into HT-29 (McCoy's 5A), RKO (MEMα), MDST8 (DMEM), A-427 (MEMα) and MIA PaCA-2 ( DMEM) was removed and cultured in RPMI medium (ThermoFisher Scientific). Cell lines were used within 15 passages of thawing and continuously cultured for less than 6 months.

For the combined dose matrix assay, 2000-3000 cells were seeded in 96-well plates in 80 μL medium per well. On day 2, serial dilutions of the two combination agents were subsequently added in 20 μL of medium, each at 6-fold the final indicated concentration. After 3 days, cell survival was measured by CellTiter-Glo Assay (Promega #G7573). The mean and standard deviation (n=3) of the percentage inhibition of compound-treated cells (relative to DMSO-treated controls) and synergy scores between the two compounds were determined. A synergy score greater than 2 is considered to have synergistic rather than additive effects.

For immunoblotting: Cells (200,000-750,000) in 2 mL of growth medium were seeded in 6-well plates (Corning, #3506). After 24 hours, cells were treated with compounds or growth factors at the concentrations and durations indicated. Cells were lysed on ice in RIPA buffer (Boston Bioproduct #BP-115) supplemented with 1 mM EDTA and Halt protease and phosphatase inhibitor mixture (Thermo Fisher Scientific #1861281). Lysates were centrifuged at 14,000 rpm for 15 minutes at 4° C. and protein concentration was determined using the BCA protein assay (Thermo Fisher Scientific). Equal amounts of protein were separated by electrophoresis in NuPAGE 4%-12% Bis-Tris gels (Thermo Fisher Scientific #WG1402BX10) and plated on nitrocellulose membranes (Bio-Rad, BX10) for immunoblotting with the indicated primary antibodies. #1704159). Conjugated primary antibodies were analyzed using the Odyssey Infrared Imager System (Li-Cor) using goat anti-rabbit IgG secondary antibody conjugated with Alexa Fluor 700 and goat anti-mouse IgG secondary antibody conjugated with IRDye 800 CW. It was visualized while scanning using The following primary antibodies were used: Phospho-ERK (Cell Signaling Technology #4370), Phospho-AKT (Cell Signaling Technology #4060), Tubulin (Cell Signaling Technology #3873), KRAS (Proteintech #12063-1-AP). , phospho-MEK (Cell Signaling Technology #9154), phospho-RSK3 (Cell Signaling Technology #9348), NRAS (Proteintech #10724-1-AP), HRAS (Proteintech #18925-1-AP), phospho-RB (Cell signaling Technology #8516), cyclin D1 (Cell signaling Technology #2978), phospho-SHP2 (Abcam #ab62322), actin (Cell signaling Technology #3700), phospho-CRAF (Cell signaling Technology #9427) and phospho-CSF1R (Cell Signaling Technology #3155).

Statistical analysis was performed and curve fits and _IC50 values were generated using GraphPad Prism 8 software. Statistical significance was determined using the unpaired, paired Student's t-test or the Mann-Whitney test. Significance was set at p=0.05.

PC14 and NCI-H1975 cells were treated with an 8×8 combination matrix of 3-fold serially diluted nazartinib from 3 μM and TNO155 from 10 μM. After 3 days (PC14) or 6 days (NCI-H1975), cell proliferation was measured using the Cell Titer-Glo® Assay and the luminescence signal for each dose combination was compared to that of the DMSO (vehicle control) group. normalized to. Percentage of growth inhibition is presented numerically as an 8x8 dose grid. The combined (Loewe excess) synergy score for PC14 cells was 5.12 and the combined synergy score for NCI-H1975 cells was 4.92.

Combinatorial synergy was observed with TNO155 and nazartinib in EGFR-mutant NSCLC cell lines, with synergy scores ranging from 2.03 to 5.12 in the cell lines tested (Figure 1). In PC14 cells, the combined synergistic effect may be due to sustained pERK inhibition and higher induction of apoptotic markers such as cleaved poly (ADP-ribose) polymerase (PARP) compared to either single agent nazartinib or TNO155.

Despite the clinical efficacy of EGFR tyrosine kinase inhibitors (TKIs) in the treatment of EGFR-mutant lung cancer and significant improvement from first- to third-generation EGFR inhibitors such as the conservative WT EGFR, acquired resistance continues to grow. , which inevitably occurs in the majority of patients. One common mechanism of resistance to EGFR TKIs is the acquisition of gatekeeper mutations in the EGFR that prevent inhibitor binding, such as T790M for first generation TKIs and C797S for third generation TKIs. Since SHP2 mediates RAS activation downstream of EGFR, the efficacy of SHP2 inhibitors may be limited if the two mutations are on the same DNA strand (cis is unaffected by the EGFR T790M and C797S mutations, even when co-occurring in the EGFR type). TNO155 is broadly effective in EGFR-mutant non-small cell lung cancer (NSCLC) cell lines. Among the 8 cell lines tested, 6 were sensitive to nazartinib/EGF816 and TNO155 was active in 3 cell lines with IC ₅₀ values below 1.5 μM (NCI- H3255, HCC827 and PC9 (see Table 1):

TNO155 has a synergistic effect with nazartinib to inhibit EGFR-mutant cell proliferation in a combined dose matrix assay. Interestingly, TNO155 and nazartinib exhibited strong synergy (synergy score>2) in 5 out of 6 nazartinib-sensitive cell lines, including 2 cell lines that were insensitive to TNO155 alone (PC14 and NCI-H1975). Indicated. A synergistic effect of nazartinib and TNO155 in PC14 and NCI-H1975 cells was observed over a wide range of concentrations of nazartinib and low concentrations of TNO155 (eg, 0.124 μM), where TNO155 exhibited single-agent activity in both strains. (see Fig. 1; Loewe excess matrix grid), demonstrating that the contribution of TNO155 arises from inhibition of another RTK signaling that could be feedback activated upon treatment with EGFR TKIs. . In PC14 cells, a rebound in p-ERK levels was observed 24 hours after treatment with 0.1 μM nazartinib after initial suppression, which could be blocked by higher doses of nazartinib (0.3 μM). could not (see Figure 2). Similarly, TNO155 effectively reduced p-ERK levels at 4 hours, but also produced a rebound at 24 hours, while the combination of TNO155 and nazartinib achieved sustained inhibition of ERK. bottom. The combination also induced a stronger apoptotic response than either single agent at 24 hours, as evidenced by increased levels of cleaved PARP (c-PARP) and BIM (see Figure 2).

Additionally, the combination of TNO155 and osimertinib, an FDA-approved third-generation EGFR TKI, was evaluated in a mouse clinical trial format in a series of tumor models derived from patients with EGFR-mutant lung cancer, including three EGFR ^(L858R) models (29666HXXTM). , 29667HXXTM and 29665HXXTM). In these models (see Figure 3), TNO155 is administered twice daily (BID) due to its short half-life in mice and its maximum tolerated dose is 20 mg/kilogram body weight (mpk). In mouse clinical trial combinations, the dose of TNO155 was reduced to 10 mpk for tolerability reasons for certain combinations. In 29666HXXTM, osimertinib (10 mpk, daily) showed only transient efficacy, while TNO155 (10 mpk, BID) effectively slowed tumor growth. It was the combination that achieved nearly complete tumor regression. In 29667HXXTM and 29665HXXTM, osimertinib had moderate and strong anti-tumor activity, respectively, whereas TNO155 had minimal activity as seen in some EGFR mutant cell lines in vitro. significantly improved the efficacy of osimertinib. These data suggest that TNO155 may overcome acquired resistance to EGFR TKIs and also improve their efficacy.

Example 2
Patients were selected who had disease amenable to biopsy at baseline and who were also on treatment during this study. Patients had activating EGFR mutations, progressed on standard of care (SOC) EGFR tyrosine kinase inhibitors (TKIs) (or no SOC EGFR TKIs available), and platinum-containing combination chemotherapy. or advanced NSCLC with a KRAS G12 mutation that progressed with SOC; or advanced HNSCC that progressed with platinum-containing combination chemotherapy; or advanced esophageal SCC that progressed with platinum-containing chemotherapy; or activated KRAS (KRAS G12C ), advanced CRC lacking NRAS or BRAF mutations and progressed on fluoropyrimidine, oxaliplatin, and irinotecan; or advanced NRAS/BRAF WT cutaneous melanoma progressed with SOC; or advanced GIST progressed with SOC had

Additionally included are patients with:
a. Advanced NSCLC with EGFR TKI-sensitizing EGFR mutations (eg exon 19 deletion, L858R) after progression on osimertinib or nazartinib.
b. Having an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) after progression on first- and/or second-generation EGFR TKIs (e.g., erlotinib, gefitinib, afatinib); Advanced NSCLC demonstrated to lack the T790 mutation after progression of .
c. Has an EGFR TKI-sensitizing EGFR mutation (e.g., exon 19 deletion, L858R) and has progressed on osimertinib as most recent therapy (continued osimertinib treatment until 2 weeks prior to starting study treatment). advanced NSCLC (and thus osimertinib may be continued during the screening period).Exceptions may be possible for patients who have recently discontinued osimertinib.

The starting dose of nazartinib in this study is 150 mg QD administered continuously. CEGF816X2101, a first-in-human trial of nazartinib, investigated doses of nazartinib ranging from 75 mg daily to 350 mg daily. A maximum tolerated dose has not been established, and antitumor efficacy was observed at all doses based on overall safety, tolerability, and efficacy data; was selected as the recommended dose for the part. Therefore, the selected dose of 150 mg QD of nazartinib is an effective dose that is less than half the highest dose tolerated in patients, thereby allowing an adequate therapeutic window for combination with TNO155. Nazartinib is primarily metabolized by CYP3A4. TNO155 is not an inducer of inhibitors of CYP3A4 and therefore the effect of TNO155 on nazartinib blood levels is not expected. The starting dose of TNO155 in combination with nazartinib is 20 mg QD, 2 weeks on/1 week off. The TNO155 regimen was 60 mg QD, 2 weeks on/1 week off and 40 mg QD, with 3 weeks on/1 week off tested and well tolerated in patients. Thus, a starting dose of 20 mg QD, 2 weeks on/1 week off, provides an adequate tolerability margin for combination with nazartinib 150 mg QD.

It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or alterations in light of them will be suggested to those skilled in the art and the present application. and within the spirit and scope of the appended claims.

Claims (28)

A method of treating cancer comprising administering (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazine to a subject in need thereof -2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, in combination with a second therapeutic agent A method comprising administering an object. The cancer is EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); medullary thyroid carcinoma; and ALK-rearranged NSCLC. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro [4.5] decan-4-amine, or a pharmaceutically acceptable salt thereof, and the second therapeutic agent are administered simultaneously, separately, or over a period of time. the method of. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl) administered to said subject in need thereof Claim 1, wherein the amount of -3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, is effective to treat said cancer. 4. The method according to any one of 1 to 3. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl) administered to said subject in need thereof -3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine, or a pharmaceutically acceptable salt thereof, and said second therapeutic agent are used to treat said cancer. A method according to any one of claims 1 to 4, which is effective for 6. The method of any one of claims 1-5, wherein the second therapeutic agent is an EGFR inhibitor. wherein the EGFR inhibitor is (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] 7. The method of claim 6, which is imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro [4.5] Decane-4-amine orally at doses ranging from about 1.5 to about 100 mg/day, (e.g., about 1.5 mg to about 60 mg/day, and about 20 mg to about 60 mg/day) 8. The method of any one of claims 1-7, wherein the method is administered. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro [4.5] Decane-4-amine is about 1.5 mg/day, or 3 mg/day, or 6 mg/day, or 10 mg/day, or 20 mg/day, or 30 mg/day, or 40 mg/day, or 9. The method of any one of claims 1-8, administered orally at a dose of 50 mg/day, or 60 mg/day, or 80 mg/day, or 100 mg/day. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) 10. The method of claim 9, wherein the -2-methylisonicotinamide is orally administered at a dose ranging from about 75 mg to about 350 mg/day. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) - 2-methylisonicotinamide administered orally at an approximate dose of about 75 mg/day, or 100 mg/day, or 150 mg/day, or 200 mg/day, or 250 mg/day, or 300 mg/day, or 350 mg/day 11. The method of claim 10, wherein (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) -2-methylisonicotinamide is orally administered at 100 mg or 150 mg/day. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) -2-methylisonicotinamide is orally administered at 150 mg/day. 1.5 mg/day, or 3 mg/day, or 6 mg/day, or 10 mg/day, or 20 mg/day, or 30 mg/day, or (3S,4S)-8-(6-amino-5-((2- A method comprising administering amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine. 15. The method of claim 14, wherein the daily dose is administered in a 21-day cycle of 2 weeks on followed by 1 week off. The cancer is EGFR-mutant non-small cell lung cancer (NSCLC); KRAS-mutant non-small cell lung cancer; head and neck squamous cell carcinoma (HNSCC); melanoma; gastrointestinal stromal tumor (GIST); medullary thyroid carcinoma; and ALK-rearranged NSCLC. 15. The method of Claim 14, further comprising a second therapeutic agent. (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro [4.5] The method of Claim 17, wherein decane-4-amine, or a pharmaceutically acceptable salt thereof, and said second therapeutic agent are administered simultaneously, separately, or over a period of time. . The method of any one of claims 14-18, wherein said second therapeutic agent is an EGFR inhibitor. wherein the EGFR inhibitor is (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d] 20. The method of claim 19, which is imidazol-2-yl)-2-methylisonicotinamide, or a pharmaceutically acceptable salt thereof. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) - 2-methylisonicotinamide is administered orally at a dose of about 75 mg/day, or 100 mg/day, or 150 mg/day, or 200 mg/day, or 250 mg/day, or 300 mg/day, or 350 mg/day 21. The method of claim 20. (R,E)-N-(7-chloro-1-(1-(4-(dimethylamino)but-2-enoyl)azepan-3-yl)-1H-benzo[d]imidazol-2-yl) -2-methylisonicotinamide is orally administered at 150 mg/day. said patient or subject has an activating EGFR mutation, has progressed on standard of care (SOC) EGFR tyrosine kinase inhibitors (TKIs) (or has no available SOC EGFR TKIs), and platinum-containing combination chemistries Advanced NSCLC that progressed on therapy; or Advanced NSCLC with a KRAS G12 mutation that progressed on SOC; or Advanced HNSCC that progressed on platinum-containing combination chemotherapy; or Advanced esophageal SCC that progressed on platinum-containing chemotherapy; or Progressed on SOC 23. The method of any one of claims 1-22, wherein the patient suffers from advanced NRAS/BRAF WT cutaneous melanoma; or advanced GIST advanced to SOC. 24. The method of any one of claims 1-23, wherein the cancer to be treated is NSCLC that is resistant or refractory to treatment with osimertinib, or a pharmaceutically acceptable salt thereof. A compound for use in a method of treating cancer, wherein said compound is TNO155, or a pharmaceutically acceptable salt thereof, and TNO155 is co-administered with nazartinib, or a pharmaceutically acceptable salt thereof compounds for use. A compound for use in a method of treating cancer, said compound being nazartinib, or a pharmaceutically acceptable salt thereof, wherein nazartinib is co-administered with TNO155, or a pharmaceutically acceptable salt thereof compounds for use. A compound for use according to claim 25 or 26, wherein said method is according to any one of claims 1-21. A pharmaceutical combination comprising TNO155, or a pharmaceutically acceptable salt thereof, and nazartinib, or a pharmaceutically acceptable salt thereof.

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